During  an endoscopy meeting in Lisbon the use of robots was extensively discussed and this promted us to write this text.

Laparoscopic surgery really started to be developed at the end of the eighties ie more than 20 years ago. Since then we witnessed its development and the progressive demonstration of its superiority in comparison with open traditional surgery.  Patients indeed have less pain, a shorter hospital stay without a scar while the surgical intervention and the complication rate remain the same.

As milestones in gynaecology we had after minor surgery, the introduction of the hysterectomy in 1990,  endometriosis surgery,  the pelvic floor surgery and promontofixation in the mid 90  followed by lympnode resection.  After 2000 not so much did change change anymore neither concerning surgical techniques nor for equipment. This can best be judged by the live surgeries  performed at the yearly meetings of the ESGE, of the AAGL and at many other dedicated meetings.

Yet the  introduction of  endoscopic surgery into main street gynaecology was much slower.  Many of the endoscopists indeed did their last laparotomy  somewhere in the last century (for me in 1996)  and performed all interventions by laparoscopy, except some extreme cases as hysterectomies for a uterus of more than 2000 grams.  This is in sharp contrast with the overall situation in most countries. In Belgium and Italy and the USA the percentages of total laparoscopic hysterectomies, considerd level I still does not reach 10%. For level II surgeries and certainly for the more advanced level III surgery the figures are even lower.  The best explanation for this is that endoscopic surgery is technically much more difficult than we anticipated 20 years ago and that it requires a long and dedicated training to perform.  In addition it has become obvious that endoscopic surgery cannot be done a little bit : unless doing surgery for at least 1 to 2 days a week the necessary skills will not be developed. In gynaecology this observation is pointing to another major problem : there is not enough surgery available in order to permit every gynaecologist to perform every week 1 day of surgery.

Then the  technology of robotic surgery was developed.  This undoubtedly is beautifil technology with some theoretical advantages as decreasing tremor,  more articulated movements which can be scaled down.  The introduction of robotic surgery to the human however occurred without clinical validation and even today 2010 I am not aware of any proven benefit of robotic surgery in comparison with conventional laparoscopic surgery, not in gynaecology, not in urology nor in any other surgical discipline .  This seems strange when considering the number of robots used in Belgium and in the USA.  Following analysis of robotic surgery we would make the following conclusions

1. We all agree that robotic surgery is not superior nor faster than conventional endoscopic surgery provided the endoscopist is a good endoscopic surgeon.
2. Robotic surgery is much more expensive than conventional laparoscopic surgery considering the price around 2.000.000 €,  the maintenance cost and the material cost of a few thousand € for each intervention.  It seems irrealistic that countries will be able to incorporate this into their public medical expenses.
3. The learning curve of robotic surgery is claimed to be shorter than the learning curve of conventional endoscopic surgery.  Yet no data exist to substantiate this claim.  Doing robotic surgery no doubt is more comfortable for the surgeon who can sit.
4. The complexity of robotic instruments is incompatible with being solid : therefore robotic surgery seem not to be appriopriated for  hysterectomies, especially not for a large uterus nor for larger myoma’s. Also larger sutures as used to close the uterus after larger myomectomies cannot be used.
4.  A new generation of robotic surgeons is emerging who never performed laparoscopic surgery and thus went from laparotomy to robotic surgery.  This I consider a dangerous situation, since these surgeons will be unable to deal with eventual complications. They will have to do a laparotomy which means at best a crucial loss of time.

In conclusion,  while being beautiful technology which merits scientific validation (in animals)  robotic surgery today  is not superior to conventional endoscopic surgery for all indications are am aware of.  Its use seem to be limited to those who are unable or unwilling to make the effort of becoming an endoscopic surgeon.  The new generation of robotic surgeons,  who go directly from laparotomy to robotic surgery are potentially dangerous when complications occur since they they will have to do a laparotomy losing time which might be crucial.

Prof P.R. Koninckx and Drssa A. Ussia

L’endometrio nelle donne con endometriosi superficiale è piu innervato. In tanti siti blog è riportato  che ciò può essere utile come test per fare una diagnosi di endometriosi.

Our Comments

This is another example (as I discussed in http://www.gynsurgery.be and http://www.mondoginecologico.it) that interpretation of research data should be done carefully and that conclusions by researchers often are overstretched and/or biased.
The observation of higher incidences of nerve fibers in the endometrium of women with endometriosis is nice research. To suggest this as a non invasive diagnostic test however is way premature.
1. First, an association does not permit to conclude about cause and effect. We know ( more than 50 articles) since 20 years that the endometrium of women with endometriosis is slightly different from the endometrium of women without endometriosis. It is unclear whether these differences are a consequence of the endometriosis or whether these differences merely signal an ‘endometrioitic’ constitution (as suggested in the endometriotic disease theory). Knowing what happens after surgical excision of endometriosis could give a hint. We previously demonstrated that the decrease in natural killer cells in endometriosis women is not affected by surgical excision of endometriosis whereas CA125 decreases tremendously therafter.
2. Second the article knowingly and willingly disregard subtle endometriosis which is present intermittently in many women and which -I and others think- should not be considered a disease, as discussed in the literature since more than 10 years.
My guess considering the pain symptoms, is that the increased nerve endings is a sign besides many others, that a women will have more retrograde menstruation and also more frequently subtle endometriosis etc, something I am considering since many years as irrelevant findings at laparoscopy since subtle endometriosis does not cause pain or infertility.
The key problem of not recognising or not referring severe endometriosis or doing an incomplete excision or doing unnecessary bowel resections will remain.

The key problem for women with endometriosis will remain the same : not recognising or not referring severe endometriosis or doing an incomplete excision or doing unnecessary bowel resections. The risk is that this observation will be used before proper validation and that it will result in a lot of unnecessary laparoscopies and surgery.
Prof P. R. Koninckx and Dr A. Ussia